IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF VIRGINIA
Richmond Division
___________________________________, Plaintiff
v.
Civil Action No. _______________
____________________________________, Defendant(s)
MOTION TO PROCEED IN FORMA PAUPERIS AND FINANCIAL AFFIDAVIT
I, ____________________________________, say that I am the plaintiff in the aboveentitled case, that I move to proceed without being required to prepay fees, costs or give security
therefor, and that in support of this motion I state that because of my poverty I am unable to pay
the costs of said proceeding or to give security therefor; and that I believe I am entitled to relief.
I further state that the responses which I have made to questions and instructions below
are true.
EMPLOYMENT
Are you employed?
_____Yes
_____No
_____Self-Employed
IF YES, How much do you earn per month? __________________________________________
Name & Address of employer: ______________________________________________
IF NO, give month and year of last employment: ______________________________________
How much did you earn per month? __________________________________________
IF MARRIED, is your spouse employed? _____Yes
_____No
IF YES, how much does your spouse earn per month? __________________________________
IF A MINOR, what is your parents’ approximate monthly income?
________________________
OTHER INCOME
Have you received within the past 12 months any income from a business, profession or other
form of self-employment, or in rent payments, interest dividends, retirement or annuity
payments, gifts or inheritance or other sources?
_____Yes
_____No
IF YES, give the amount received and identify the source(s):
$______________________ Received from Source(s)_________________________________
$______________________ Received from Source(s)_________________________________
CASH
Have you any cash on hand or money in savings or checking accounts? _____Yes
_____
No
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Total Amount: Checking $__________
Savings $__________
Other $__________
PROPERTY
Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property
(excluding ordinary furnishings and clothing)?
_____Yes
_____No
IF YES, give value and describe it:
Value
Description
$______________________
$______________________
________________________________________________
________________________________________________
MARITAL STATUS
_____ Single _____Married
_____Widowed
_____Separated or Divorced
DEPENDENTS
Total Number of Dependents: _____
List persons you actually support, your relationship to them and how much you contribute
toward their support:
_____________________________________ ______________________________________
_____________________________________ _______________________________________
DEBTS & MONTHLY BILLS
List all creditors, including banks, loan companies, charge accounts, etc.:
Creditors
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Total Debt
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
Monthly Payment
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ______________________
(Date)
__________________________________________
(Signature)
Address: ________________________________________________
_______________________________________________
________________________________________________
Phone Number: ________________________________________________
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